Zoom-Out: ‘Zoom-Out’ means that the physician includes a wide-angle-lens approach towards care that focuses primarily on dysfunction associated with the complaint (symptoms felt + changes in ability to do an action), but likely does not explain only the LBP.
In medicine, the common and usual model is a routine: (1) the reason for the visit, (2) evaluate the complaint, (3) compare treatment options to care supported within the patient’s insurance plan, (4) recommend care that addresses the symptoms. However, that is all wrong.
My practice is based on the idea of the ‘whole patient approach.’ This means that I start my conversation with my LBP patient by stepping back and observing them with a wide-angle lens…Zoom-Out. I collect this information: (1) the reason for the visit, (2) the meaning of the symptoms to the patient, (3) the patient’s values and expectations regarding their care, (4) any economic & social contributors toward their care, (5) the ability of the patient to learn and understand their participation with their care program, and, (6) any of their personal biases about anything related to their care. I bill accordingly since E&M codes allow for enough time to perform a proper evaluation; therefore, there is no reason to rush.
I stand behind all of the care that I manage in my office. My patients are assured that they will feel better today, that I will not delay their care, and that the reason (mechanism of injury) will be clearly explained to them. My practice ‘brand’ is that I will resolve the patient’s problem within 1-4 visits at low cost; however, I am usually proficient enough to get it solved in one visit. I am fascinated by advanced imaging, but I do not rely on advanced imaging, since its utility is primarily to confirm a diagnosis, not to make one. Patients are not pictures.
‘Zoom-Out’ means that the physician includes a wide-angle-lens approach towards care that focuses primarily on dysfunction associated with the complaint (symptoms felt + changes in ability to do an action), but likely does not explain only the pain; SCAD: symptomatic compensation to associated dysfunction.
“Education has been considered to play three different parts in relation to back pain: (1) as a predictor of frequency, (2) outcome episodes, (3) surgical and rehabilitative interventions performed. Low socioeconomic status (SES) was significantly associated with increased prevalence of back pain…strongly associated with [different/not primary] language used. People with low education and low paying jobs are more likely to work in physically demanding jobs and tasks involving stresses on the spine, …less satisfied, …poorer sick leave benefits, and fear loss of jobs because of back pain… do less well in the health care system… and [find it difficult] to use services effectively.” (Dionne, et.al. 2001)
Doctors look at pain as something to be removed, not understood. Pain is not the VAS scale. It is not a frown face or a smiley face. Pain is not an MRI of a disc herniation. Pain starts to have meaning when your patient is bent over holding their back. Pain is intolerably bad medical advice, again. Pain is needles and scalpels. Pain is witnessing a head-on car crash in real time. Pain is watching a 6-year-old boy dressed in a suit, crying, with his forehead on his father’s casket. Pain is a patient sensation AND a patient disruption AND a threat to patient sensibilities.
There are social aspects to LBP complaints and ability to get excellent care: these are commonly attributed to beliefs within their groups: certain types of care are not allowed, religious beliefs, gender values, age values, patriarchal/matriarchal values, intergenerational values… the “should and should-nots” within the many groups that the patient may belong to…fears about gender identity, languages spoken or understood, ethnic/race identity & history, ethnicity or race/gender of the clinician, beliefs about types of care, social class expectations and history, education, ethnically-based diet, ideas about equality, and social pressure to self-medicate (smoke, vape, chew, drink, trendy pain pills.)
There are economic aspects to LBP complaints and ability to get excellent care: these are commonly attributed to financial class, job title, job satisfaction, collar-class, wage and wage-safety, affordability for insurance (deductible, monthly, cash, supplies, medications), geography: ability to book and get to appointments, ability to get supplies and medication, child care, debt & credit issues (medical), food-safety & nutrition, internet access, proximity to toxins & poor sanitation, and the like.
Do you code any of these with your LBP cases?
F43.9 Reaction to stress, F45.7 State of emotional shock, Z 63.4 Bereavement, Z59.9 Housing insecurity Z56 Employment problems, Z62 Negative life events, Z56.2 Threat of job loss, Z56.81 Sexual harassment, Z63.5 Divorce, Z63 Primary family support problems, Z63.8 Caregiver stress, Y07 neglect by family member. (ICD10data.com)
‘Pain is not the only problem.’ Any combination socio-economic aspects can contribute to LBP, or make it worse, and must be considered. Is the clinician contributing the problematic failure of care when these aspects are ignored? Simply coding for LBP is not enough. Advocate for your patients by practicing beyond the common and usual model, Zoom-Out.
LBP Blog General information
These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.
Dr. Dean Bio
Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020. www.preformancecxs.org
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